Nurse Care Manager

Who We Are Evergreen Nephrology partners with nephrologists to transform kidney care through a value-based, person-centered, holistic, and comprehensive approach to kidney care. We believe patients living with kidney disease deserve the best care. We are committed to improving patient outcomes and improving quality of life by delaying disease progression, shifting care to the home, and accelerating kidney transplants. We help nephrologists focus on the right patients at the right time across the full care spectrum. We do this by providing them with the best-in-class interdisciplinary clinical resources, analytical insight and tools, and services to patients. We listen to the needs of our patients, our employees, and our client partners, continually working to push beyond the status quo in which the care system manages patients today. Who You Are You are devoted, compassionate, and enjoy being on the front lines of healthcare, changing the lives of patients by supporting them and the team by focusing on customers. You’re excited about being part of a team that is building a healthcare delivery model that ensures the highest possible quality of life and best outcomes for those in our care. You believe people living with kidney disease deserve the best person-centered, holistic, comprehensive care and want to influence the healthcare system to drive towards that. You thrive in innovative and evolving environments with high rates of change. Your Role This role may be filled by a Registered Nurse (RN) or a licensed Physical Therapist (PT) meeting equivalent qualification criteria. As a Post Acute Nurse Care Manager, you are responsible for collaborating with Skilled Nursing Facilities to manage nephrology patients who are receiving skilled nursing care after acute hospitalization. This role focuses on ensuring their skilled nursing stay promotes efficiency as well as meeting their specialized needs based on their individual conditions with a coordinated plan to discharge to home or community. Your job duties will include taking full ownership of patient care management within your caseload, including engaging with Skilled Nursing Facility staff, providers, patients, and their caregivers. You will perform assessments to identify needs based on individual values, goals, and preferences. While this position is fully remote , you must be able to work 8:30am – 5pm in the Central or Eastern time zone. Role Responsibilities Some responsibilities may vary based on specific patient programs, but this role's primary duties include the following: Manage the overall care management of patient caseload by leveraging experience, expertise, and knowledge in both the nursing field and value-based care operations. Facilitate seamless transitions for nephrology patients from a Skilled Nursing Facility to home or community. Collaborate with hospital discharge planners, providers and SNF staff to ensure patients’ needs are addressed. Monitor patient progress in skilled nursing facilities and identify barriers to timely discharge. Actively participate in clinical huddles, IDT meetings, and patient care conferences for patients under your care management. Develop and implement strategies to optimize length of stay while maintaining high-quality care. Support seamless transitions of care as patients move between care settings, proactively addressing potential barriers and collaborating with internal and external care team stakeholders. Establish trusting relationships with patients and families to provide clinical and emotional support and foster collaboration throughout their care journey. Perform assessments and identify the needs, including social determinants of health, of caseload patients and caregivers based on values, care goals, and individual preferences, and translating these into patient-centric actionable care plans. Identify and develop SNF stakeholders and foster relationships for communication and coordination of care. Identify areas for…